Day care surgery.

In recent years, day surgery rates have risen in many countries in the world. In 1998-99, 65% of elective surgery was performed as day procedures in the UK and about 70% in the USA. The future has the potential for an increase in day surgery as less well-performing countries and hospitals catch up with the best, and new surgical, anaesthetic and analgesic techniques are introduced. Consolidation and development of best management practices are necessary for sustained day surgery development.

Day surgery--the future.

Day surgery is a cost effective, quality approach to treatment which has expanded rapidly in recent years. Changes in attitude and the introduction of new technology will ensure its future growth as long as the purchasers of health care do not focus only on its cost savings aspect but equally concentrate on its quality benefits.

A prospective study of bilateral inguinal hernia repair.

A prospective study of outcome after inguinal hernia repair in patients undergoing simultaneous repair of bilateral hernias (n = 31), sequential repair of bilateral hernias (n = 5), and unilateral hernia repair (n = 75) is reported. There were no differences in wound complications, post-operative respiratory complications, or other adverse effects in the three groups. Operating time was similar in the unilateral and bilateral simultaneous repairs (median 55 min), but was longer (100 min) for the combination of two sequential repairs. Hospital stay was shortest for patients undergoing unilateral repair (2 days) but was less with bilateral simultaneous repair (4 days) than after two sequential repairs (total of 6 days). There were 12 (11%) wound complications of which five (5%) were infections. There was no difference in complication rate between unilateral and bilateral hernia repair. Postoperative recovery was assessed prospectively and was recorded at 1 month. There was no difference between unilateral and bilateral simultaneous repairs in the number of days before the patient was able to climb stairs easily, drive a car or return to work. The duration of the requirement for analgesia was similar in each group. We conclude that bilateral simultaneous hernia repair can be carried out with no greater morbidity than a unilateral repair, and the return to normal activity is as rapid. Bilateral hernias should be repaired simultaneously rather than sequentially.

Admission to hospital after day case surgery.

This paper reports a 5-year experience of a surgical day case unit. Over 10,000 patients were treated in the three specialties of gynaecology, orthopaedics and general surgery. Seventy patients (0.7%) were admitted to the inpatient beds of the hospital directly from the day case unit. These patients were reviewed to determine if any avoidable factors had played a part. Two-fifths of the admissions after suction termination of pregnancy were of patients of more than 12 weeks' gestation. Admission was necessary on 10 occasions after orthopaedic and general surgical operations when the procedure was too extensive or too painful to allow the patient to be discharged home. Complications of anaesthesia, either local (n = 5) or general (n = 15), constituted the largest cause for admission. Postoperative nausea, vomiting and drowsiness became less frequent after a change in technique to the use of a short-acting anaesthetic agent (12 in the 3 years before; two in the 2 years after). Day case surgery is safe and should rarely be followed by the need for hospital admission. Based on our experience, we recommend the use of short-acting agents for general anaesthesia, and we advise against day case surgery in patients who require a general anaesthetic for longer than 60 min, or who need extensive surgery.

Effect of a surgical day unit on waiting lists.

The effect of a surgical day unit (SDU) on the waiting lists of a busy district general hospital is reported over a 4-year period. During this time, 18 (15%) of the general surgical beds were closed for financial reasons. A real saving rather than an apparent one is reported due to the work expansion in the SDU.

Recurrence rates following local anaesthetic day case inguinal hernia repair by junior surgeons in a district general hospital.

Four hundred and seventy one inguinal hernia repairs were performed by surgeons in training as day cases using local anaesthesia between September 1979 and December 1982. All patients were sent questionnaires relating to the possibility of a recurrence or an unsatisfactory outcome of the operation at a mean of 34 months after surgery. A 96.8% retrieval rate was achieved. As a result of answers received 62 patients were examined. Nineteen recurrences (4.2%) were diagnosed by an independent assessor; a rate of 2.2% for indirect and 8.2% for direct inguinal herniae. No UK series approaches this operation frequency and none has junior surgeons as the sole operators. The recurrence rate is comparable with many in-patient and short stay series. As a result of this day unit, local waiting times for hernia repairs have dropped from 2 years to 6 weeks.

Outpatient varicose vein surgery under local anaesthesia.

Local anaesthesia has been used for 186 varicose vein operations performed in a day surgical unit. The long saphenous vein was stripped in 87 legs using a femoral nerve block. All patients went home on the day of operation and none required readmission. Complications were minimal and included six wound infections, six episodes of thrombophlebitis and one case of saphenous neuritis; 35 patients had minor residual varices at 6 weeks of which 29 required injection sclerotherapy. The technique has been shown to be both safe and acceptable to patients, and reduced the waiting time for surgery to a mean of 3.1 months during the period studied.

Variable symptomatology in idiopathic retroperitoneal fibrosis.

Idiopathic retroperitoneal fibrosis is uncommon enough to be placed low down on a list of differential diagnoses of any problem facing a general surgeon in a district hospital. In this paper, 4 cases of retroperitoneal fibrosis are described, all of whom presented within a 5-year period to the same surgeon; each described a different symptomatology. This paper serves to reiterate the diversity of presenting features in retroperitoneal fibrosis and to demonstrate that this condition may not be as rare as is widely believed.

Day case inguinal hernia repair under local anaesthetic.

Local anaesthetic day case inguinal hernia repair has been performed on 135 patients under the care of one surgeon in a nine month period. Results of a questionnaire answered by 129 patients (95.6%) and 31 of their general practitioners (85%) have been analysed. The complication rate is very low and both patient and GP acceptability is high.

The treatment of recurrent pulmonary embolism: experience with the Kimray Greenfield vena cava filter.

Clinical experience with the Kimray Greenfield vena cava filter in 24 patients, most of whom suffered recurrent pulmonary embolism despite heparin treatment, is presented. The advantages of this filter over previous trans-venous filters is discussed. Initial results show the filter to be both safe and effective.

Blood viscosity, Raynaud's phenomenon and the effect of fibrinolytic enhancement.

The whole blood and corrected blood viscosity of 17 patients with Raynaud's phenomenon (8 with idiopathic Raynaud's phenomenon and 9 with scleroderma-associated Raynaud's phenomenon) have been compared with 12 normal controls. Viscosity has been measured with a Contraves LSV1 rotating viscometer and the Wells-Brookfield microviscometer at 37 degrees C and 25 degrees C and shear rates ranging from 0.775 s-1 to 230 s-1. Blood viscosity was higher at both the lower temperature and the lower shear rates but this change was the same in the patients as in the normal subjects. There was a significantly higher level of plasma fibrinogen in the patients with scleroderma with a significant increase in the corrected blood viscosity, but not the whole blood viscosity, at both temperatures and all shear rates. The percentage increase of viscosity at low temperatures in the patients was the same as the controls. No evidence was found to substantiate the hypothesis that Raynaud's phenomenon is caused by an excessive increase of blood viscosity at low temperatures. Treatment of 10 patients with stanozolol, a stimulator of fibrinolysis, reduced the plasma fibrinogen and increased the haematocrit did not change the whole blood viscosity. Hand blood flow increased. The improvement of hand blood flow was not therefore caused by change in blood viscosity secondary to the reduction of plasma fibrinogen.

Venous lipodermatosclerosis: treatment by fibrinolytic enhancement and elastic compression.

The value of fibrinolytic enhancement with an anabolic steroid (stanozolol) combined with elastic stockings in treating venous lipodermatosclerosis was assessed in a six-month double-blind cross-over trial. Thirty-four legs of 23 patients in whom other treatments had failed were studied. The patients were randomly divided into two groups who were treated with either stanozolol plus elastic stockings or placebo plus elastic stockings for three months, and then vice versa. Treatment with or without stanozolol caused the area of lipodermatosclerosis to decrease, but the rate of healing when patients took stanozolol was double that when they took the placebo, and this was assumed to be biologically important. Stanozolol also reduced the incidence of extravascular fibrin detected in skin biopsy specimens. The elastic stocking with placebo produced significant decreases in leg volume, ankle circumference, and skin thickness. Stanozolol is valuable in treating intractable lipodermatosclerosis, giving relief of pain and reducing induration, inflammation, tenderness, and pigmentation.

Treatment of Raynaud's phenomenon by fibrinolytic enhancement.

Twenty patients with advanced Raynaud's phenomenon, in 14 of whom it was secondary to scleroderma, were treated with stanozolol, an anabolic steroid that enhances natural fibrinolysis. All showed an increase in hand blood flow and a reduction in symptoms during treatment. This response may have been caused by the lysis of fibrin deposited in the digital arteries and the reduction of plasma viscosity. Stanozolol is a useful addition to the treatment of patients with advanced Raynaud's phenomenon who have trophic changes.

Treatment of liposclerosis of the leg by fibrinolytic enhancement: a preliminary report.

Fourteen patients with longstanding lipodermatosclerosis of their lower legs, secondary to venous disease in 11, were treated for three months with stanozolol, a drug that enhances fibrinolytic activity. No other treatment was given and no change made in existing treatment. All the patients improved. Two were cured in three months, three were able to stop treatment in the next three to 11 months, and the other nine continued to improve. Fibrinolytic enhancement, with stanozolol, seems to be a worthwhile addition to the treatment of venous liposclerosis and deserves further study.